DOCSLIB.ORG

Limitation of Resuscitation Documentation and Orders, 11647 Policy/Procedure PURPOSE

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
Limitation of Resuscitation Documentation and Orders, 11647 Policy/Procedure PURPOSE Current Status: Active PolicyStat ID: 8646610 Originated: 10/1/2013 Effective: 10/3/2020 Last Approved: 2/19/2021 Last Revised: 2/19/2021 Next Review: 2/19/2024 Owner: Joan Roberts: Research Principal Investigator Document Area: Clinical Standards & Regulations: Document Types: P&P, Priority A, Priority B Limitation of Resuscitation Documentation and Orders, 11647 Policy/Procedure PURPOSE: 1. To allow for and encourage documentation of discussions regarding goals of medical care, limitation of resuscitation, and/or end of life decisions for each individual child and family. 2. To provide an easily accessible written record of these discussions in order to avoid unnecessary repetition of emotional and complex discussions for families. 3. To provide guidance to health care providers about the rationale and procedure for writing limitation of resuscitation orders. 4. To COPYprovide medical providers with a clear and explicit plan for resuscitation prior to a medical emergency. Note: This policy refers to limitation of resuscitation rather than "Do Not Resuscitate" or "Do Not Attempt Resuscitation" to avoid the connotation of discontinuing care or commitment to our patients. POLICY: Cardiopulmonary resuscitation (CPR) is a potentially life saving, emergency intervention that should be initiated when cardiopulmonary function is physiologically inadequate to sustain life. However, there are circumstances where the burdens of these emergent resuscitation measures potentially outweigh the benefits within the context of the goals of care. Under these circumstances, providers and other care team members as directed by the attending, should review the goals of care with families, discuss the potential burdens and benefits of these emergent measures, and document these conversations in the Patient's medical record. Decisions regarding specific interventions should be provided within the limitation of resuscitation order set. PROCEDURE: I. DEFINITIONS A. Cardiopulmonary Resuscitation (CPR): An attempt to restore cardiac and pulmonary function when cardiopulmonary function is physiologically inadequate to sustain life. Procedures may include Limitation of Resuscitation Documentation and Orders, 11647. Retrieved 3/25/2021. Official copy at Page 1 of 11 http://seattlechildrens.policystat.com/policy/8646610/. Copyright © 2021 Seattle Children's Hospital placement of an artificial airway, artificial respiration, chest compressions or cardiac massage, electrical cardioversion, and the administration of resuscitative medications. These efforts are implemented under the guidelines of the American Heart Association for different patient populations, including neonates (NRP), pediatric patients (PALS) and adults (ACLS). B. Limitation of Resuscitation Order: An order to describe the emergent resuscitative interventions that should be provided when cardiopulmonary function is physiologically inadequate to sustain life. This order is compatible with maximal efforts, other than resuscitation or other identified life sustaining interventions, to treat the patient with therapeutic measures including, but not exclusive of, surgery, medicines, intensive care or other interventions aimed at palliation or cure. It is not a signal to abandon or ignore the patient; rather, it implies a previously identified and alternative supportive care plan. C. Code Status: Descriptive term used to provide an overview of the goal-directed approach to providing emergent resuscitative measures when cardiopulmonary function is physiologically inadequate to sustain life. This term is posted on the Patient Summary Page in the electronic health records. Options include "Full Support, indicating that all resuscitative efforts should be performed and "Limited Support", indicating that specific resuscitative efforts or comfort care should be provided according to the goals of care. The Code Status of each Patient should be reviewed by all health care providers caring for the Patient. D. Patient/Parent(s): Throughout this document, the term "Parent(s)" refers to the Surrogate Decision Maker for the Patient when the Patient is a Minor or is incapacitated. Please refer to Administrative P&P, Legally Authorized Person for Informed Consent Decision Making, 10628 for full details. "Patient" acknowledges that Patients 18 years and older and Emancipated Minors are the legal decision maker, unless they are incapacitated. Patients 18 years and older may make decisions to limit resuscitation in conjunction with an Advance Directive or in isolation. Please see Bioethics P&P, Advance Directive, 10033 for more information. Furthermore, when the Patient is a Minor, considerations should be made to include the Patient, when developmentally and neurocognitively appropriate, in the decision making process. II. PROCEDURECOPY FOR DISCUSSING AND DETERMINING CODE STATUS (See Appendix II.) A. Establish goals of care: Under all circumstances of hospitalization, the provider team should facilitate a conversation with the Patient/Parent(s) to: 1. Ascertain the Patient/Parent(s) understanding of the disease process. 2. Review options for treatment, including the potential risks, benefits, and alternatives. 3. Elicit the values and preferences of the Patient/Parent(s). 4. Based on the recommendations of the Attending Physician and within the context of the values and preferences of the Patient/Parent(s), identify the goals of medical care. These discussions are likely iterative and ongoing, as the goals of care evolve and change over time throughout the course of an illness. B. Review and documentation of Code Status: Depending on the underlying disease process, potential therapies and treatments, preferences and values of the Patient/Parent(s), and goals of medical care, there are two circumstances in which providers should consider reviewing and discussing with Patient/Parent(s) the possibility of limiting resuscitation. In both of these circumstances, it is imperative to remember that unique personal, familial, religious, or cultural Limitation of Resuscitation Documentation and Orders, 11647. Retrieved 3/25/2021. Official copy at Page 2 of 11 http://seattlechildrens.policystat.com/policy/8646610/. Copyright © 2021 Seattle Children's Hospital factors may make attempting CPR unusually beneficial. 1. Relative benefits and burdens of attempting CPR are uncertain (i.e. life limiting diseases that have not reached terminal stages): Based on the goals of care as discussed with the Patient/Parent(s), prior experience, medical knowledge, and empirical data, the provider team may determine that attempting CPR is a plausible option, however there is a great level of uncertainty in outcome, and CPR potentially could be more burdensome than beneficial. a. The provider team should review the goals of care, discuss the potential benefits and burdens of attempting CPR, acknowledge the uncertainty in outcome with the Patient/ Parent(s), and offer CPR as a plausible option. b. The provider team should assist, guide, and support the Patient/Parent(s) with the decision to either attempt or limit resuscitation depending on the goals and values of the Patient/ Parent(s). Reasonable efforts should be made to effectively communicate information necessary to enable a reasoned evaluation and voluntary decision. c. The discussion should be documented and the limitation of resuscitation order should be completed by a provider according to the discussion. See Section III. 2. Burdens of attempting CPR likely outweigh the benefits (i.e. life limiting diseases in the terminal stages): Based on the goals of care as discussed with the Patient/Parent(s), prior experience, medical knowledge, and empirical data, the Attending Physician may determine that the burdens of attempting CPR likely outweigh the benefits. a. The provider team should review the goals of care and discuss with the Patient/Parent(s) that the burdens of attempting CPR likely outweigh the benefits. To prevent causing unnecessary harm to the patient, the provider team should recommend against attempting CPR. b. If the Patient/Parent(s) assent to limiting resuscitation, the discussion should be documented and a limitation of resuscitation order should be written. See Section III. COPYc. If the Patient/Parent(s) do not assent to limiting resuscitation, the discussion should be documented and full or modified resuscitation orders should remain in place, according to the wishes and preferences of the Patient/Parent(s). See Section III. III. DOCUMENTATION OF CODE STATUS AND WRITING LIMITATION OF RESUSCITATION ORDERS A. Under either of the circumstances described in section II, the provider team should document the key aspects of the conversation(s) and decision(s) using the format provided in the electronic health record. 1. These conversations should be documented regardless of the decision to limit resuscitation. For example, if full resuscitative efforts should be attempted, the conversations, decisions, values and goals should be documented and orders for attempting full resuscitation should be placed. 2. Documentation of key components of the conversation and decisions should include: a. Names and roles of Individuals who participated in the conversation. If two or more providers were involved, all names should be listed. b. Current medical diagnoses and expected prognosis of patient. c. General content of the conversation(s) including the goals of medical care, values and preferences of the Patient/Parent(s). Limitation of Resuscitation Documentation and Orders, 11647.
Load more

Recommended publications
  • Management of Acute Liver Failure In
    Management of Acute Liver Failure in ICU Philip Berry MRCP, Clinical Research Fellow, Institute of Liver Studies, Kings College Hospital, London, UK Email: [email protected] Self assessment questions Scenario: A twenty-year-old female is brought into the Emergency Department having been found unconscious in her bedsit. There is no other recent history. She did not respond to a bolus of 50% dextrose in the ambulance, despite having an unrecordable blood glucose when tested by the paramedics. While she is being intubated on account of reduced level of consciousness, an arterial blood gas sample reveals profound lactic acidosis (pH 7.05, pCO2 2.5 kPa, base deficit – 10, lactate 13 mg/L). Blood pressure is 95/50 mmHg. 1. What are the possible explanations for her presentation? Laboratory tests demonstrate hepatocellular necrosis (AST 21,000 U/L) and coagulopathy (INR 9.1) with thrombocytopenia (platelet count 26 x 109/L). Acute liver failure appears the most likely diagnosis. 2. What are the most likely causes of acute liver failure (ALF) in this previously well patient? Her mean arterial blood pressure remains low (50mmHg) after 3 litres of colloid and crystalloid. The casualty nurse, who is doing half-hourly neurological observations, reports reduced pupillary response to light. 3. What severe complications of ALF may result in death within hours, and what are the immediate management priorities for this patient? Introduction Successful management of this rare but potentially devastating disorder relies on early recognition. The hallmark of acute liver failure (ALF) is encephalopathy (ranging from a subtle alterations in consciousness level to coma) in the context of an acute, severe liver injury.
    [Show full text]
  • Validation of Lactate Clearance at 6 H for Mortality Prediction in Critically Ill Children
    570 Research Article Validation of lactate clearance at 6 h for mortality prediction in critically ill children Rajeev Kumar, Nirmal Kumar Background and Aims: To validate the lactate clearance (LC) at 6 h for mortality Access this article online prediction in Pediatric Intensive Care Unit (PICU)-admitted patients and its comparison Website: www.ijccm.org with a pediatric index of mortality 2 (PIM 2) score. Design: A prospective, observational DOI: 10.4103/0972-5229.192040 study in a tertiary care center. Materials and Methods: Children <13 years of age, Quick Response Code: Abstract admitted to PICU were included in the study. Lactate levels were measured at 0 and 6 h of admission for clearance. LC and delayed or nonclearance group compared for in-hospital mortality and compared with PIM 2 score for mortality prediction. Results: Of the 140 children (mean age 33.42 months) who were admitted to PICU, 23 (16.42%) patients died. For LC cut-off (16.435%) at 6 h, 92 patients qualified for clearance and 48 for delayed or non-LC group. High mortality was observed (39.6%) in delayed or non-LC group as compared to clearance group (4.3%) (P = 0.000). LC cut-off of 16.435% at 6 h (sensitivity 82.6%, specificity 75.2%, positive predictive value 39.6%, and negative predictive value 95.7%) correlates with mortality. Area under receiver operating characteristic (ROC) for LC at 6 h for mortality prediction was 0.823 (P = 0.000). The area under ROC curve for expected mortality prediction by PIM 2 score at admission was 0.906 and at 12.3% cut-off of PIM 2 Score was related with mortality.
    [Show full text]
  • Package for Emergency Resuscitation and Intensive Care Unit
    Package for Emergency Resuscitation and Intensive Care Unit Extracted from WHO manual Surgical Care at the District Hospital and WHO Integrated Management for Emergency & Essential Surgical Care toolkit For further details and anaesthetic resources please refer to full text at: http://www.who.int/surgery/publications/imeesc/en/index.html 1 1. Anaesthesia and Oxygen XYGEN KEY POINTS: • A reliable oxygen supply is essential for anaesthesia and for any seriously ill patients • In many places, oxygen concentrators are the most suitable and economical way of providing oxygen, with a few backup cylinders in case of electricity failure • Whatever your source of oxygen, you need an effective system for maintenance and spares • Clinical staff need to be trained how to use oxygen safely, effectively and economically. • A high concentration of oxygen is needed during and after anaesthesia: • If the patient is very young, old, sick, or anaemic • If agents that cause cardio-respiratory depression, such as halothane, are used. Air already contains 20.9% oxygen, so oxygen enrichment with a draw-over system is a very economical method of providing oxygen. Adding only 1 litre per minute may increase the oxygen concentration in the inspired gas to 35–40%. With oxygen enrichment at 5 litres per minute, a concentration of 80% may be achieved. Industrial-grade oxygen, such as that used for welding, is perfectly acceptable for the enrichment of a draw-over system and has been widely used for this purpose. Oxygen Sources In practice, there are two possible sources of oxygen for medical purposes: • Cylinders: derived from liquid oxygen • Concentrators: which separate oxygen from air.
    [Show full text]
  • Anytown Trauma Center Trauma Protocols
    ANYTOWN TRAUMA CENTER TRAUMA PROTOCOLS TITLE: TRAUMA TEAM ACTIVATION PROTOCOL PURPOSE: The purpose of the protocol is to establish guidelines for trauma team activation and define the members of the responding trauma team to facilitate the resuscitation and management of critical or seriously injured patients who require rapid, organized resuscitation, evaluation and stabilization to promote optimal outcomes. It also serves to provide triage guidelines for adult and pediatric patients. PROCESS: 1. TRAUMA TEAM ACTIVATION PROTCOL A. The criteria for activation of the trauma team is clearly defined and posted at the Emergency Department triage desk, by the EMS communication station and in the resuscitation rooms. B. The trauma team may be activated prior to arrival based on the EMS communication and their assessment. C. The trauma surgeon, emergency medicine physician, emergency department charge nurse/ house supervisor, emergency department nurses and the Trauma Program Manager may activate the trauma team. D. The person calling the trauma activation will initiate the trauma page to group page the trauma team and will specify the MOI, BP, HR, ETA and level of activation required and age if available. E. If the trauma team members are present in the emergency department and alert is still communicated to ensure everyone is notified. F. Trauma team member notification and arrival times will be documented on the trauma flow sheet (paper or electronic). G. Trauma team members will sign-in when they arrive. H. Trauma team members will be activated for all patients who meet the following criteria: 1. Level 1 trauma activation (major): life threatening injuries and/or unstable vital signs, limb-threating or disability threatening injury 2.
    [Show full text]
  • Central Venous Catheter (CVC) Placement
    Medical Education Policy: Central Venous Catheter (CVC) Placement Facility: CMC Origin Date: June 2015 Revision Date: March 2019 Sponsor: GMEC 1. PURPOSE: Carilion Clinic is committed to excellent patient care, with the highest priority towards patient safety and excellent clinical outcomes. As a graduate medical education training site, Carilion Clinic will standardize the basic education, competency assessment, supervision and procedural methods for medical students, resident physicians and fellows inserting central venous catheters (CVCs) under this policy. This policy will guide the education of trainees in the use of proper sterile technique, anatomical landmarks and ultrasound guidance when inserting CVCs. The CVCs covered by this policy are all percutaneously inserted central catheters including large bore central catheters such as dialysis and resuscitation catheters. This policy supports the routine use of ultrasound guidance for internal jugular and femoral venous sites of CVC placement unless the clinical urgency and/or immediate unavailability of ultrasound precludes sonographic guidance. At times, extraordinary clinical circumstances or clinical judgment of the attending physician may dictate that different approaches to central line placement may be utilized. It is expected that these will be an unusual occurrences. 2. SCOPE: This policy outlines the education, training and supervision of all trainees involved in CVC insertion. All postgraduate medical trainees performing CVC placement in their clinical duties will be trained in anatomic landmarks and ultrasound guided CVC insertion techniques as appropriate to location. This policy designates the minimum standard by which a resident or fellow will be educated to place CVCs, when they may place central lines WITHOUT direct supervision, and who may supervise and teach central line placement.
    [Show full text]
  • Mass Casualty Incident (MCI) Response Module 1
    Mass Casualty Incident (MCI) Response Module 1 (Hamilton County Fire Chief's Association, 2013) 1 Objectives Purpose: This module will educate staff on mass casualty triage incident response, including how to: • Define mass casualty triage • Determine considerations for adults and pediatrics • Understand the importance of a patient tracking system • Recognize and implement the patient admission/ discharge MCI triage process • Determine how to appropriately handle the deceased in a large-scale MCI • Recognize the range of incidents that may cause MCIs 2 MCI Basics 3 What is an MCI? • A mass casualty incident (MCI) is an incident where the number of patients exceeds the amount of healthcare resources available. • This number varies widely across the country, but is typically greater than 10 patients. 4 Types of MCI Notifications • During a large scale incident such as a mass casualty, it is important to have a mass notification system. Successful mass notification systems will: . Internally: alert staff to activate MCI protocols and prepare for a potential surge of patients . Externally: increase community awareness 5 Assisting in MCI Response Considerations for hospital staff in an MCI: • Some patients may arrive to the hospital without having been assessed/ triaged at the scene • MCI response requires efficiency and coordination • Non-clinical personnel (including hospital volunteers) can assist in moving patients to designated areas based on level of care • Help gather patient information in the emergency treatment area • Staff should review patients in clinical assignment for any potential discharges/ transfers to make room for potential MCI admissions, a process known as “surge discharge” (Chung S, 2019) 6 Triage Basics Definition of MCI Triage Triage means “to sort.” Triage in an MCI is the assignment of resources based on the initial patient assessment and consideration of available resources.
    [Show full text]
  • Trauma Resuscitation and the Damage Control Approach
    SURGERY FOR MAJOR INCIDENTS anatomy’). This philosophy has increasingly been adopted in the Trauma resuscitation and the civilian environment. DCS describes the specific, systematic surgical approaches damage control approach focussing on normalizing physiology from the dual insults of injury and surgery, as opposed to providing immediate definitive Nathan West repair.3,4 DCRad incorporates diagnostic and interventional Rob Dawes radiological solutions used to treat severely injured patients.5 Recent history of trauma care Abstract Haemorrhage remains the biggest killer of major trauma patients. One- Advances in trauma care commonly occur during warfare, where third of trauma patients are coagulopathic on admission, which is exacer- high numbers of seriously injured soldiers are treated, although a bated further by other factors. Failure to address this results in poor out- landmark change was the introduction of the Advanced Trauma Ò comes. Damage control resuscitation is current best practice for bleeding Life Support (ATLS) programme in 1978. ATLS was originally trauma patients, and encompasses damage control surgery and damage targeted at doctors with little expertise in trauma and provides a control radiography. This review provides a summary of the latest con- structured system for recognizing life-threatening problems and cepts in the rapidly evolving field of trauma resuscitation management. instigating appropriate interventions. The ATLS ‘Airway, Keywords Damage control; massive haemorrhage; resuscitation; trauma Breathing, Circulation, Disability, and Exposure’ (ABCDE) mantra is familiar the world over. Whilst it is likely this approach has saved many lives over the years, with the advent of regional Introduction trauma networks and experience gained from large recent mili- tary campaigns, an approach that reaches beyond ATLS is now Damage control (DC) was first termed to describe measures required in civilian practice.
    [Show full text]
  • Cerebrovascular Resuscitation After Polytrauma and Fluid Restriction
    Cerebrovascular Resuscitation after Polytrauma and Fluid Restriction Steven A Earle, MD,MarcAdeMoya,MD, Jennifer E Zuccarelli, BA, Michael D Norenberg, MD, Kenneth G Proctor, MD, PhD BACKGROUND: There are few reproducible models of blast injury, so it is difficult to evaluate new or existing therapies. We developed a clinically relevant polytrauma model to test the hypothesis that cerebrovascular resuscitation is optimized when intravenous fluid is restricted. STUDY DESIGN: Anesthetized swine (42 Ϯ 5 kg, n ϭ 35) received blasts to the head and bilateral chests with captive bolt ϭ guns, followed by hypoventilation (4 breaths/min; FiO2 0.21). After 30 minutes, resuscitation was divided into phases to simulate typical prehospital, emergency room, and ICU care. For 30 to 45 minutes, group 1, the control group (n ϭ 5), received 1L of normal saline (NS). For 45 to 120 minutes, additional NS was titrated to mean arterial pressure (MAP) Ͼ 60 mmHg. After 120 minutes, mannitol (1g/kg) and phenylephrine were administered to manage cerebral perfusion pressure (CPP) Ͼ 70 mmHg, plus addi- tional NS was given to maintain central venous pressure (CVP) Ͼ 12 mmHg. In group 2 (n ϭ 5), MAP and CPP targets were the same, but the CVP target was Ͼ 8 mmHg. Group 3 (n ϭ 5) received1LofNS followed only by CPP management. Group 4 (n ϭ 5) received Hextend (Abbott Laboratories), instead of NS, to the same MAP and CPP targets as group 2. RESULTS: Polytrauma caused 13 deaths in the 35 animals. In survivors, at 30 minutes, MAP was 60 Ͼ Ͻ to 65 mmHg, heart rate was 100 beats/min, PaO2 was 50 mmHg, and lactate was Ͼ 5 mmol/L.
    [Show full text]
  • Characteristics, Course and Outcomes of Children Admitted to a Paediatric Intensive Care Unit After Cardiac Arrest
    This open-access article is distributed under Creative Commons licence CC-BY-NC 4.0. RESEARCH Characteristics, course and outcomes of children admitted to a paediatric intensive care unit after cardiac arrest J Appiah,1,2,3 MB ChB, MWACP, MPhil, Cert Crit Care (Paed); S Salie,1,2 MB ChB, DCH, FCPaed, Cert Crit Care (Paed); A Argent,1,2 MB ChB, MMed(Paed), MD(Paed), DCH (SA), FCPaed (SA); B Morrow,2 PhD, BSc (Physiotherapy) 1 Paediatric Intensive Care Unit, Red Cross War Memorial Children’s Hospital, Cape Town, South Africa 2 Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa 3 Paediatric Intensive Care Unit, Department of Child Health, Komfo Anokye Teaching Hospital, Kumasi, Ghana Corresponding author: J Appiah ([email protected]) Background. Cardiac arrest is a potentially devastating event, associated with death or severe neurological complications in survivors. There is little evidence on paediatric cardiac arrest prevalence, characteristics and outcomes in South Africa (SA). Objective. To describe the characteristics, course and outcomes of children admitted to an SA paediatric intensive care unit (PICU) following cardiac arrest. Methods. Retrospective descriptive study of routinely collected data (January 2010 - December 2011). Results. Of 2 501 PICU admissions, 110 (4.4%) had preceding cardiac arrest. The median (interquartile range (IQR)) age of children was 7.2 (2.5 - 21.6) months. In-hospital arrests accounted for 80.6% of the events. The most common primary diagnostic categories were respiratory (29.1%), cardiovascular (21.4%) and gastrointestinal (21.4%). Twenty-four patients (23.3%) arrested during endotracheal intubation.
    [Show full text]
  • Cardiopulmonary Resuscitation: to Intubate Or Not to Intubate
    ISSN 2379-4046 EMERGENCY MEDICINE Open Journal PUBLISHERS Editorial Cardiopulmonary Resuscitation: To Intubate or Not to Intubate Chien-Chang Lee, MD, ScD1*; Jon Wolfshohl, MD2; Eric H Chou, MD2 1Department of Emergency Medicine, National Taiwan University, Taipei 106, Taiwan 2Department of Emergency Medicine, John Peter Smith Hospital, Fort Worth, Texas, USA *Corresponding author Chien-Chang Lee, MD, ScD Department of Emergency Medicine, National Taiwan University Hospital, No. 7, Chung-Shan South Road, Taipei 100, Taiwan; Tel. +886-2-23123456 ext 62831; Fax. +886-2-23223150; E-mail: [email protected] Article information Received: July 27th, 2018; Accepted: August 20th, 2018; Published: August 20th, 2018 Cite this article Lee C-C, Wolfshohl J, Chou EH. Cardiopulmonary resuscitation: To intubate or not to intubate. Emerg Med Open J. 2018; 4(1): e1-e3. doi: 10.17140/EMOJ-4-e005 INTRODUCTION intrathoracic pressure resulting in depressed coronary perfusion pressure.4,5 Coronary perfusion pressure is the single most impor- ardiopulmonary resuscitation (CPR) is a “tug of war” between tant indicator for return of spontaneous circulation (ROSC). Low Clife and death. The most suspenseful and technically difficult coronary perfusion pressure (CPP) results in low ROSC rate. Giv- task in the resuscitation process is often endotracheal intubation. en the potential harm associated with tracheal intubation during re- However, the benefits of endotracheal intubation during CPR suscitation, a bold hypothesis was postulated: using a less invasive have been seriously challenged in recent literature.1 way of ventilation, such as bag-valve-mask ventilation or laryngeal mask ventilation, in place of tracheal intubation during CPR may POTENTIAL HARMS OF ENDOTRACHEAL INTUBATION reduce the interruption of chest compression and could improve DURING RESUSCITATION the CPR success rate.4-7 Establishment of an advanced airway to maintain gas exchange EVIDENCE FROM OBSERVATIONAL STUDIES and oxygenation has been viewed as an essential life-saving pro- cedure during resuscitation.
    [Show full text]
  • Sepsis ACP 2019
    Sepsis ACP 2019 • Are sepsis bundles good for patient care? • Politics • CMS requirements • New York’s Rory Staunton Law • Industry involvement Controversial • Is the science sound? • Emergency room physician petition to retire guidelines • More than 5800 ER physicians signed petition Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016 Critical Care Medicine 2017. 45(3):486 • Initial Resuscitation. • At least 30 mL/Kg of IV crystalloid fluid within first 3 hours • After initial resuscitation, additional fluids guided by frequent reassessment • MAP >65 mm Hg • Guiding resuscitation to normalize lactate in patients with elevated lactate levels as a marker of tissue hypoperfusion. • Appropriate routine microbiologic cultures before starting antimicrobial therapy and within one hour. • Empiric coverage for all likely pathogens • Combination therapy for initial management of septic shock • Procalcitonin levels to support shortening duration of therapy. Sepsis Guidelines Continued: • Source control intervention be implemented as soon as medically and logistically practical. • Fluid therapy. • Fluid challenge technique with continued fluid administration as long as hemodynamics factors continue to improve. • Vasopressors. • Norepinephrine as the first-choose vasopressor • Adding vasopressin 0.03 U/min or epinephrine. • Recommend against IV hydrocortisone if adequate fluid resuscitation and vasopressor are able to restore hemodynamics stability. Sepsis Guidelines Continued • Transfusion only when
    [Show full text]
  • Surviving Sepsis Campaign Hour 1 Bundle
    Hour-1 Bundle Initial Resuscitation for Sepsis and Septic Shock 3 5 ! Administer broad- Apply vasopressors if MEDICAL spectrum antibiotics. hypotensive during or EMERGENCY after fluid resuscitation to maintain a mean arterial Initiate bundle upon 4 pressure ≥ 65 mm Hg. recognition of sepsis/septic shock. Begin rapid May not complete all bundle elements administration of within one hour of recognition. 30 mL/kg crystalloid for hypotension or lactate ≥ 4 mmol/L. 1 68 Measure lactate level. 100/50 96 Remeasure lactate 14 if initial lactate elevated (> 2 mmol/L). 2 Obtain blood cultures before administering antibiotics. Bundle: SurvivingSepsis.org/Bundle Complete Guidelines: SurvivingSepsis.org/Guidelines © 2019 the Society of Critical Care Medicine and the European Society of Intensive Care Medicine. All Rights Reserved. BUNDLE HOUR-1 BUNDLE: INITIAL RESUSCITATION FOR SEPSIS AND SEPTIC SHOCK: 1) Measure lactate level.* 2) Obtain blood cultures before administering antibiotics. 3) Administer broad-spectrum antibiotics. 4) Begin rapid administration of 30mL/kg crystalloid for hypotension or lactate ≥4 mmol/L. 5) Apply vasopressors if hypotensive during or after fluid resuscitation to maintain a mean arterial pressure ≥ 65 mm Hg. *Remeasure lactate if initial lactate elevated (> 2 mmol/L). © 2019 the Society of Critical Care Medicine and the European survivingsepsis.org Society of Intensive Care Medicine. All Rights Reserved. 1. *Act quickly upon sepsis & septic shock recognition 2. Minimize time to treatment - sepsis & septic shock are medical emergencies 3. Monitor closely for response to interventions 4. Communicate sepsis status in hand-offs *All elements of the Hour-1 bundle may or may not be completed in the first hour after sepsis recognition survivingsepsis.org BUNDLE HOUR-1 BUNDLE: INITIAL RESUSCITATION FOR SEPSIS AND SEPTIC SHOCK: 1) Measure lactate level.* 2) Obtain blood cultures before administering antibiotics.
    [Show full text]